Updated 02 June 2015

Traumatic brain Injury

TBI occurs when a sudden physical assault on the head causes damage to the brain.

Seven-times Formula One world champion Michael Schumacher is in a critical condition after suffering head injuries in a skiing accident in the French Alps resort of Meribel.

The retired motor racing star fell while skiing off-piste (on unmarked slopes littered with rocks and tree stumps hidden under a blanket of snow) on Sunday morning. "He suffered head trauma with coma that needed prompt neurosurgical treatment ... He remains in a critical condition," Schumacher's agent Sabine Kehm said in a statement.

Doctors operated on the 44-year-old German, drilling holes in his skull to reduce internal pressure. This procedure is known as a craniotomy.

Chief anesthesiologist professor Jean-Francois Payen said: "It was an impact on his right side with high speed. He could not answer questions after the accident."

"We can say he is fighting for his life. We judge him to be in a very serious situation. We cannot tell what the outcome will be yet. We are working hour-by-hour but it's too early to say what is going to happen and to have a prognosis.

Schumacher was initially conscious as he was transported to a local hospital in Moutiers and then to Grenoble. However, his condition deteriorated sharply afterwards

Doctors treating Schumacher in Grenoble gave a press conference on Monday and according to a report on the conference published by The Guardian, they said:

• He is being kept at a steady temperature (34-35C) and under general anaesthetic to reduce external stimulus

• Had Schumacher not being wearing a helmet "he would not have got to here". According to Bild, the helmet broke during the fall.

• It is too early for the doctors to give a prognosis.

Reading between the lines

Dr Gary Hartstein, former FIA Medical Delegate for the F1 World Championship, has written evaluating the press conference. You can read his full analysis here. Here is an extract:

"We know that besides keeping Michael deeply asleep, they've also slightly lowered his body temperature. This is part of the strategy to optimise the brain’s metabolic state. Along with increasing the delivery of “good stuff” to the brain, reducing the temperature reduces the brain’s need for stuff. Therefore the supply:consumption relation is rendered more favourable.

We’ve been told that Michael has bilateral lesions. This mean the brain is wounded in both hemispheres. That shouldn't surprise us. This was a hard hit. What kind of “lesions”? While we haven’t been told exactly, we can assume a mix of three types.

First, the hematoma itself. This is a collection of blood that can be evacuated. That’s been done, and Michael will be examined and scanned regularly in order to detect the formation of any new hematoma, or re-accumulation of the original one.

A diagram of a subdural hematoma, a potentially fatal brain injury which doctors think Michael Schumacher suffered after hitting his head on a rock.

Head trauma - what it is

Head injury or Traumatic Brain Injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain. The damage can be focal, confined to one area of the brain, or diffuse, involving more than one area of the brain. Head injuries can result from a closed head injury or a penetrating head injury.

A closed head injury occurs when the head suddenly and violently hits an object, without the object breaking through the skull. A penetrating head injury occurs when an object pierces the skull and enters the brain tissue.

Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain.

This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull, an injury called "contrecoup".

Shaken baby syndrome is a severe form of head injury that occurs when a baby is shaken forcibly enough to cause extreme contrecoup injury. Damage to a major blood vessel within the head can cause a haematoma, or heavy bleeding into or around the brain.

The severity of a head injury can range from a mild concussion to the extremes of coma or even death. A coma is a profound or deep state of unconsciousness.

Symptoms

Symptoms of a head injury may include headache, nausea, confusion or other cognitive problems, a change in personality, depression, irritability, and other emotional and behavioural problems. Some people may have seizures as a result of a head injury.

Diagnosis

CT scanning is the gold standard for the radiologic assessment of a head-injured patient. A CT scan is easy to perform and is an excellent test for detecting the presence of blood and fractures, which are the most important lesions to identify in emergency situations.

Plain x-rays of the skull are recommended by some people as a way to evaluate patients with only mild neurologic dysfunction. However, most large centres in South Africa have readily available CT scanning, which is a more accurate test. For this reason, the routine use of skull x-rays for head-injured patients has declined.

Magnetic resonance imaging (MRI) is not commonly performed for acute head injury because it takes longer to perform than a CT scan, and because transporting an acutely injured patient from the emergency room to the MRI scanner is difficult.

However, after a patient has stabilised, MRI may demonstrate the existence of lesions that could not be detected by CT. Such information is generally more useful for determining prognosis than for influencing treatment.

Prognosis

The outcome of TBI depends on the cause of the injury and on the location, severity, and extent of neurological damage: outcomes range from good recovery to death. Doctors often use the Glasgow Coma Scale to rate the extent of injury and chances of recovery.

The scale (3-15) involves testing for three patient responses: eye opening, best verbal response, and best motor response. A high score indicates a good prognosis and a low score indicates a poor prognosis.

Treatment

Like all trauma patients, persons with head injury need a systematic yet rapid evaluation in the emergency room. Cardiac and pulmonary functions are the first priority. Next, a rapid examination of the entire body is performed. Immediate treatment for head injuries involves surgery to control bleeding in and around the brain, monitoring and controlling intracranial pressure, insuring adequate blood flow to the brain, and treating the body for other injuries and infection.

To consider, some contusions or hematomas may enlarge over the first hours or days after head injury, so that some patients are not taken to surgery until several days after an injury. Sometimes these delayed hematomas are discovered when a patient's neurologic exam worsens or when the ICP increases.

On other occasions, a routine follow-up CT scan that was ordered to see if a small lesion has changed in size indicates that the hematoma or contusion has enlarged significantly. In many of these cases, removing the lesion before it enlarges and causes neurologic damage may be safest for the patient.

Reviewed by Dr Andrew Rose-Innes, Assistant Professor of Neurology, University of Washington.

Ask the Expert

Dr Elliot Shevel is a South African migraine surgery pioneer and the founder and medical director of The Headache Clinic in Johannesburg, Durban and Cape Town, South Africa. The Headache Clinic is a multidisciplinary practice dedicated to the diagnosis and treatment of Primary Headaches and Migraines. Dr Shevel is also the main author of all scientific publications generated by his team. He recently won a high level science debate in which he was able to prove that the current migraine diagnosis and classification is not based on data. Tertiary Education - Dr Shevel holds both Dental and Medical degrees, and practises as a specialist Maxillo-facial and Oral Surgeon. Follow the Headache Clinic on Twitter@HeadacheClinic.

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